DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
HFS 107.22, Wis. Admin. Code
F-11076B (10/08)
FORWARDHEALTH
PRIOR AUTHORIZATION / RESIDENTIAL CARE CENTER
TREATMENT SERVICES ATTACHMENT (PA/RCCA)
For Continuing Services
Instructions: Type or print clearly. Before completing this form, read the PA/RCCA Completion Instructions, F-11076C.
SECTION I — MEMBER INFORMATION
1.
Name — Member (Last, First, Middle Initial)
2.
Date of Birth
3.
Member Identification Number
SECTION II — PROVIDER INFORMATION
4.
Name – Residential Care Center (RCC)
5.
National Provider Identifier
SECTION III — CLINICAL INFORMATION
6.
Attach documentation of a HealthCheck screen by a valid HealthCheck screener dated within one year prior to the first date of
service requested.
7.
Attach a copy of the in-depth assessment performed within 30 days of admission which has been timely reviewed and signed
by a physician or other licensed mental health professional.
8.
Attach a copy of the detailed narrative describing progress on the goals of earlier treatment plans, as well as a copy of the
current treatment plan, dated within three months of the requested first date of service, which has been timely reviewed and
signed by a physician or other licensed mental health professional. Indicate the expected schedule if the member is receiving
intermittent services for stabilization at the RCC.
SECTION IV — SIGNATURE
9.
SIGNATURE — Residential Care Center Clinical Supervisor
10. Date Signed
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